Vet Clin Small Anim 37 (2007) 165179

VETERINARY CLINICS
SMALL ANIMAL PRACTICE

Ethical Dilemmas in Veterinary Medicine

Carol A. Morgan, DVMa,*, Michael McDonald, PhDb
a

Interdisciplinary Studies Graduate Program, The University of British Columbia, Room 230, 6356 Agricultural Road, Vancouver, British Columbia, Canada V6T 1Z2 b The W. Maurice Young Centre for Applied Ethics, The University of British Columbia, 6356 Agricultural Road, Vancouver, British Columbia, Canada V6T 1Z2

thical issues often spark emotional reactions [1,2], making communications pertaining to these issues challenging. Ethics, considered as beliefs or principles governing what is right and wrong, may be categorized according to the sphere to which they pertain: personal, social, or professional [3]. Professional ethics are set apart because professionals pledge or profess to uphold a societal good [4]. Professional status carries obligations that are role-dened, meaning that once accepting the role of a professional, the individual promises to behave in certain ways [5]. Flowing from their professional status, veterinarians have a wide range of responsibilities, including those to clients, colleagues, the profession, and the public [3,6,7]. They also have responsibilities regarding the care and well-being of animals [810]. These responsibilities frequently conict, with the result that veterinarians are constantly confronted with ethical issues. Veterinarians are called upon to serve as an advocate of both parties interests, even when these interests conict [11]. This makes veterinary ethics complex and difcult. The tension that veterinarians feel in trying to serve patients and clients has been called the fundamental question in veterinary medical ethics [3,12]. Conicting responsibilities create what many refer to as veterinary dilemmas [11,1320]. A moral dilemma, in a strict sense, is a conict between responsibilities or obligations of exactly equal moral weight. In a wider sense, moral dilemmas occur when there are competing responsibilities with no obvious way to prioritize one responsibility over others. Achieving agreement about the moral weight of responsibilities to animals is difcult, because the moral status of animals is a source of profound debate [21]. Some suggest that it is nonsense to speak of moral claims for animals at all [22,23]. Others claim that animals have an important moral status in society [3,12,24]. In veterinary medicine, the moral status of animals seems to be uid [25,26] and ambiguous [14,27,28]. This leaves interpretations of veterinarians responsibilities open
*Corresponding author. E-mail address: camorgan@interchange.ubc.ca (C.A. Morgan). 0195-5616/07/$ see front matter doi:10.1016/j.cvsm.2006.09.008 2007 Elsevier Inc. All rights reserved. vetsmall.theclinics.com

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to debate and dispute. In contrast to other professions, veterinarians must deal with a centrally contested moral claimthe moral status of animalsin their day-to-day interactions with clients and patients. In a looser and more common sense, the term dilemma is used to refer to moral choices that are hard to make because of contextual factors, such as potential negative responses from clients or loss of income. These situations are not moral dilemmas in a strict sense, because an ethically correct solution is apparent but is difcult to enact. For example, a veterinarian may know that a client engages in dog ghting but chooses not to report the client to humane authorities because he or she worries that the client may retaliate by taking his or her business elsewhere or threatening extralegal action. Ethically, the obvious course of action is to report the client, because dog ghting is considered to be abuse and is illegal in most jurisdictions [3]. Beyond legal proscriptions, veterinarians are ethically responsible to reduce animal suffering [8,9]. Nevertheless, pragmatically, veterinarians worry about the actual consequences of calling humane authorities over fear of loss of income or even reprisals [29]. It is also true that these cases may be difcult to document and are often unsuccessful. Although, ethically, a clearly correct course of action exists, veterinarians may nd themselves seeking other alternatives. These hard choices may also be termed practical dilemmas, because the right action is a difcult one to take. In veterinary medicine, it may be difcult to separate practical and moral dilemmas. For example, some veterinarians oppose tail docking in dogs because it does not benet the patient and causes some harm. Some of these veterinarians who oppose docking may feel compelled to perform the procedure to placate a good client, however. This is a practical dilemma. Other veterinarians view tail docking as a moral dilemma because they are uncertain how to prioritize the clients right to make decisions regarding his or her pet versus the veterinarians responsibility to mitigate animal suffering. Dilemmas commonly reported in the veterinary literature are likely a combination of practical and moral dilemmas and include requests by clients to perform unnecessary procedures (cosmetic surgery), requests to perform procedures that are harmful or stressful to the animal (eg, minor surgery without anesthesia), requests for euthanasia of healthy animals, breaking client condentiality to protect animals, and refusal by or inability of clients to provide the necessary resources (eg, nancial, time, housing) for care of patients, to name only a few. Veterinarians and veterinary staff generally try to negotiate these situations with their clients in an ethically responsible and respectful way, but doing so can be challenging. Communication regarding dilemmas is an important skill for veterinarians to enable them to fulll their professional responsibilities to patients, clients, colleagues, and the public. SOURCES OF ETHICAL TENSION IN VETERINARY MEDICINE When interacting with clients and staff, it is important for veterinarians to understand that there are several sources of moral dilemmas. Differences in beliefs regarding the importance of animals, differences in beliefs regarding

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responsibilities to animals, differences in assessment of the interests of animals, and differences in the interpretation of their professional role can all lead to ethical tension. Differences in Valuing Animals As already noted previously, a signicant source of disagreement in veterinary medicine is the moral importance of animal well-being. Even in companion animal practice, where animals are often considered members of the family, views of the moral value or worth of animals vary from person to person. The issue is whether the interests of an animal are morally signicant in their own right or only matter insofar as they are tied to the interest of human beings (eg, owners, neighbors, society). For example, some have argued that animals have no or minimally morally relevant interests because they are purely for the use of people [22,23,30]. This strongly anthropocentric (human-centered) view maintains that animals matter only insofar as they matter to people. From this perspective, companion animals may be viewed as morally signicant simply because they serve the needs of people through companionship or service (therapy dogs). From an anthropocentric stance, once an animal is no longer considered useful, dispensing with the animal humanely is a morally acceptable option. Clients who claim to love their pet yet request euthanasia of a healthy animal because they are moving are likely viewing animals anthropocentrically. The pet has literally outlived its usefulness to the client. At the opposite pole, biocentrism places signicant moral value on biologic life, including animals, rather than on membership in the human species, as do anthropocentrists. These two poles create a continuum of moral inclusion ranging from humans only to all biologic life. Particularly relevant to veterinary medicine, others place signicant moral weight on sentience or the ability to experience life on some conscious level [3133]. Animals have interests in their own right quite apart from the interests of persons. The interests of food, happiness, and continued life should be counted on the same basis as similar interests in people [31,32]. Some veterinarians, veterinary staff, and clients likely have some biocentric or sentientist beliefs that animals have interests worth considering on their own merits. In general, veterinarian and client beliefs may be placed on a spectrum ranging from strongly anthropocentric views to strongly biocentric views. Clients who say Its just a dog and veterinarians who think Its just a wild bird are placing these animals in an order of moral importance. Such values underpin the degree to which people weigh the interests of animals against their own interests, for example, to save money or time. Alternatively, veterinarians may fail to offer extensive diagnostics on a hamster because they consider the animal to be less morally important (or assume that the client does) than a dog or cat. Veterinarians and clients may value animals in conicting ways, leading to confusion or disagreement. Differences Regarding Responsibilities to Animals Aside from the question of the moral status of animals in relation to human beings, another source of divergence between veterinarians, staff, and clients

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is about the level of responsibility involved in owning or caring for an animal. Although particular individuals may agree that animals have a moral status, they may differ about human responsibilities to pets [34,35]. Most jurisdictions have legal requirements for animal care, including the provision of food, water, and shelter. How much care is owed to animals remains a source of debate, however, particularly when we move beyond the bare necessities of animal life and health. Lets assume that clients are responsible for routine preventative care (eg, immunizations, parasite control) and for treatment of at least minor injuries. Are they also responsible for treatment of complex medical problems (eg, diabetes mellitus, Cushings disease) or for the treatment of medically complex injuries? Is the morally appropriate level of care contingent on the clients ability to pay or only on the clients willingness to pay? If the former, should clients be expected to sacrice their interests or the interests of family members to pay for veterinary care? Beyond dening the responsibilities that clients have to their animals, veterinarians and clients may disagree over which animals are owed these responsibilities. Many practitioners are familiar with clients who present a stray cat for minimal treatment only to discover that the cat has lived in the clients home for the past 10 years. It seems that some clients believe they have different responsibilities to animals that are found compared with those that are actively acquired. Alternatively, veterinarians may encounter clients who consent to extensive treatment of a found dog for which they plan to nd a home once it recuperates, because it is the right thing to do. Some veterinarians may discourage extensive care on the found animal because they do not believe that their client should be deemed responsible. The levels of veterinary care for which pet owners are responsible is open to debate, but so are the circumstances that activate these responsibilities. Differences Regarding the Interests of Animals A third source of ethical disagreement is in the assessment of an animals best interests. Even when veterinarians and clients hold similar views regarding the importance of animals and responsibilities to animals, differences can occur in deciding what is best for the patient or what counts as ill health [36]. These situations parallel cases in which parents or guardians disagree with physicians regarding what counts as appropriate medical care for a child or incompetent adult (one who is not capable of making decisions because of physical or mental impairment). Clinical medical ethics focus on means and methods for determining the best outcome for a patient through substituted or proxy decision making [37]. Ethical issues include who should be making decisions and how these decisions are made [38]. Clinical ethicists work with physicians and families to articulate what may be important to the patient and in the patients interests and whether this might be achieved through medical intervention (or not). This sort of dialogue has only just started in veterinary medicine with the recent focus of dening animal welfare and assessing quality of life in companion animals [3943]. For example, a practitioner may rmly believe that

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a dog with chronic arthritis is going to benet from long-term analgesic use; however, the owner of the dog may be more concerned with the development of side effects and refuse to medicate the animal. In this case, the veterinarian and the client both want to serve the best interests of the animal but differ on what those interests are. Differences Regarding Veterinarians Role Finally, clients and veterinarians (and veterinary staff) may hold differing beliefs with respect to the ethical role that the veterinarian should play in relation to clients and patients. Some may see veterinarians as advocates for their patients, whereas others see the veterinarian as serving the clients best interests. Another view is that the veterinarians role is merely to provide information so that clients are in a position to decide what services they want (C.A. Morgan, DVM, University of British Columbia, Vancouver, Canada, dissertation in progress) [44]. Each of these perspectives on the veterinarians appropriate role leads to different approaches to information disclosure to clients and to the acceptability of paternalistically directing client choices. For example, a veterinarian may consider himself or herself an advocate for the patient and, based on his or her beliefs, may offer only the information likely to induce clients into making a decision that he or she believes is in the animals best interests (C.A. Morgan, DVM, University of British Columbia, Vancouver, Canada, dissertation in progress) [44]. This veterinarian may feel perfectly justied in directing a client toward a certain treatment and decide not to disclose all available options. In the example noted previously, a practitioner may minimize or downplay potential analgesic drug side effects in treating an arthritic dog, considering that the benets of treatment far outweigh the risks. Many clients prefer veterinarians to provide information that allows the client to make decisions, however [45]. Such clients expect the practitioner to supply information necessary for them to make a decision based on their own beliefs regarding the importance of their pet, their responsibilities to their pet, and the interests of their pet. When veterinarians, clients, and staff have conicting notions of veterinarians moral responsibilities, miscommunication is likely to occur. STRATEGIES TO AVOID OR MANAGE ETHICAL TENSIONS In medical encounters, physicians and patients communicate by using four different types of interactions, including information gathering, education and counseling, relationship building, and activation and partnership [46]. Communicating about ethical issues can involve phases similar to communications with clients about medical issues. A key step in working through ethical problems in veterinary practice is dening, or diagnosing, the source of the ethical conict. In other words, veterinarians should attempt to gather information to discover the reason for the tension, including the commonly noted sources of tension as mentioned previously. An essential rst step in gathering information about values is to reect on ones own beliefs, perceptions, and values [47]. Veterinarians and their staff

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may be unaware of their own stance regarding the standing of animals, their roles and responsibilities, and the sorts of responsibilities clients owe to their animals. Conversely, they may be under the assumption that clients (or staff) have similar views regarding animals or vice versa, leading to misinterpretations and difculties when discussing ethical issues. Practitioners should use self-reection to understand their own values, beliefs, and biases before engaging in this type of dialogue with clients. It may be benecial to have these discussions during practice meetings or decompression sessions. Emanuel and Emanuel [48] argue that patients in human medicine may be unaware of their own values or that these values change over time. In exploring the patients values, a physician may be better able to provide recommendations for treatment. Further, these authors suggest that value articulation may include encouraging patients to consider what sort of values they ought to have rather than the values that they do have. Fulford [49] suggests that medicine should be value based as well as evidence based. Not only should the facts and scientic data count in the decision process, but the values relating to patient preferences should inuence treatment plans. Just as value articulation and value-based medicine are important in the human eld to ensure that human patients receive adequate support and information from their health care providers, value articulation may be even more important in veterinary medicine because of the moral uidity and ambiguity regarding the moral status of veterinary patients. It is important for practitioners to engage clients in conversations regarding how they value their pet. For example, open-ended questions about how they obtained the animal, why they obtained the animal, and the way the animal is cared for and by whom can all provide insight into the value of the pet. It is important then to bring to the surface the beliefs and expectations of clients and, when appropriate, to explore alternative perspectives with them. Equally important is to revisit these beliefs on an ongoing basis, because values may change over time. Once discovering the values underpinning an ethically problematic situation, practitioners may nd it necessary to discuss with clients the roles and responsibilities of veterinarians. For example, clients may (mistakenly) believe that veterinarians are required to follow their wishes and directions blindly. When a veterinarian refuses to practice according to the clients wishes, for example, to extract a loose tooth without anesthesia, the client may feel confused or angry because he or she believes that the veterinarian should fulll his or her wishes as a paying customer. That the client has an inalienable right to choose is a common perspective in veterinary practice and is bolstered by the increasing prevalence of a business orientation by practitioners. Diligent veterinarians recognize the importance of educating their clients about the responsibilities and obligations of veterinarians. In addition to the obligation to treat clients fairly, veterinarians are responsible for reducing pain and suffering in animals and for maintaining public trust by providing appropriate care to animals. Veterinarians engaging in harmful practices to animals, even at the clients request, not only adversely affect the well-being of patients but may advance the

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deterioration of public trust in the veterinary profession. In such situations, it is appropriate that practitioners remind clients that veterinarians have professional obligations beyond those they have to clients. In addition to clarifying the role and responsibilities of veterinarians and veterinary staff, veterinarians may need to inform clients about responsibilities associated with pet ownership. In situations in which a veterinarian believes a client is failing to provide adequate care to an animal, the practitioner should initiate a dialogue focusing on those responsibilities. In most jurisdictions, legislation requires animal owners to provide for basic necessities. Veterinarians should be familiar with local legislation and its interpretation by the humane authorities. Beyond these bare minimums, veterinarians should consider counseling clients regarding responsibilities based on their authority as an animal health expert [50]. The type and degree of responsibilities that people have to their pets is uncharted territory in some cases, however, and veterinarians should be open to respectful dialogue with clients and not leap to conclusions. Ideally, dialogue regarding values, roles, and responsibilities should begin early in the veterinary-client relationship. Veterinary staff may wish to nd ways to demonstrate or articulate their values regarding animals, their roles and responsibilities, and expectations for clients during relationship-building phases of an appointment. Initiating this sort of dialogue before an issue arises may make moral discussion and value articulation easier in future appointments. For example, during a rst meeting, a breeder of bulldogs may ask a veterinarian if he or she is willing to perform elective caesarian sections on his or her bitches. The veterinarian may take the opportunity to discuss his or her views, in an open and honest fashion, regarding management of heritable problems in purebred dogs and invite the client into the discussion. Having discussed the clients beliefs regarding animal use and responsibilities, practitioners may be able to anticipate scenarios in which ethical problems may arise. Building a rapport with clients in nonurgent circumstances may allow for better management of crises when they do occur. The fourth task in medical encountersactivation and partnershipmay serve as a useful tool in resolving difcult choices. For example, veterinarians faced with the prospect of euthanizing a healthy animal may believe that they only have two alternatives: to respect the clients wishes and agree to euthanize or to turn the client away and refuse to euthanize the pet. Because neither option actually protects the patient, some veterinarians choose the morally questionable alternative of agreeing to euthanize and then covertly nd a new home for the pet. For many veterinarians, this is a signicant moral dilemma. It is important for a veterinarian in this situation to explain his or her position to the client, including his or her values and beliefs about veterinarians responsibilities for animals. He or she may then ask the client how to resolve the situation in a manner that is acceptable to all parties. Other options do exist, such as referring clients to a humane organization, assisting the client in nding a new home for the pet, or signing over ownership of the pet to the veterinarian. Mobilizing clients to nd alternative solutions to ethical problems that have

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been highlighted during value articulation and responsibility clarication phases may result in win-win solutions that defuse morally problematic situations. CREATING MORAL BOUNDARIES Regardless of extremely effective communication surrounding ethical issues, practitioners and clients sometimes have profoundly different views regarding an acceptable course of action. At times, clients refuse all alternatives and maintain their position with respect to treatment or nontreatment. Veterinarians should feel comfortable in drawing boundaries by indicating clearly what they consider to be inappropriate solutions to a problem. There are several ways to articulate these boundaries. For example, it may be possible to develop hospital policies around issues that occur frequently, such as use of perioperative analgesia, surgery aimed at correcting behaviors (eg, debarking, declawing), cosmetic surgery, euthanasia, and questionable care (possible abuse or neglect). Common problem situations may be discussed during practice meetings to develop thoughtful and well-researched policies that all members of the veterinary team can support. It is important that veterinarians and staff understand the rationale for these policies and can articulate the reasoning to clients who seek information relevant to them. Many ethical questions arise in nonroutine situations in which decisions are heavily context driven, such as a clients unwillingness to pursue diagnostics or treatment options. In some situations, veterinarians may believe that they cannot continue to engage in the veterinary-client relationship and may consider terminating the relationship. Doing so may have negative consequences for the patient, however. In addition, terminating the veterinarian-client-patient relationship may be impossible in some situations. For example, a client may request continued hospital care for a cat in the end stages of feline infectious peritonitis (FIP), even after repeated recommendations by the veterinarian to consider euthanasia. The client may hold religious beliefs that preclude euthanasia or may refuse to admit that his or her pet has a terminal disease. The client may even refuse to allow the veterinarian to administer analgesics or sedation to reduce the patients suffering from fear of hastening death. In these situations, veterinarians should not accede to client requests. After clarifying their roles and responsibilities to the client and attempting to understand the clients motivation, the veterinarian may need to notify the client that failing to address pain or anxiety in a terminal condition is unacceptable. The veterinarian may need to serve the client an ultimatum that allows him or her to manage the patients pain or, otherwise, seek outside assistance, such as humane authorities. Similarly, practitioners may encounter situations in which the level of care provided by the client is marginal and attempts to communicate with the client do not seem to have any benet for the patient. In these cases, practitioners may need to seek the services of humane organizations while maintaining the veterinary-client patient relationship. Alternatively, a practitioner could refer his or her client to a trusted colleague in the hope

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that another veterinarians opinion may inuence the client rather than simply ring the client. Establishing these boundaries may highlight the importance of patient care to clients but may also minimize moral stress to practitioners. To develop boundaries in contextually complicated situations, practitioners may apply decision-making frameworks to assist them in working through ethical issues [5153]. These frameworks assist practitioners (and possibly clients) in working through moral questions. In larger hospitals or referral institutions, more formal mechanisms, such as ethics committees or clinical ethicists, may facilitate dialogue among veterinary staff and between veterinary staff and clients and their families [54]. Increasing the structure of ethics talk within the veterinary hospital through these more formal mechanisms may provide a level of objectivity and consistency important to increasing condence in decisions. SOME IMPORTANT CONSIDERATIONS There are several important factors that veterinarians should consider when discussing ethical issues. As professionals, veterinarians hold a certain level of power in the veterinarian-client relationship not only through their knowledge and expertise but because they can limit or enable access to medications and treatments to clients and patients. It is important to remember that formal veterinary ethical and legal structures focus on ensuring the autonomy of clients and their right to make their own decisions. The informed consent doctrine requires that veterinarians provide the appropriate information to clients in a fashion that clients can understand [55]. To treat a patient well or avoid harming a patient, however, veterinarians sometimes are compelled to limit, bias, or omit information to satisfy their own needs, the veterinarians perceived needs of the client, or the perceived needs of the patient (C.A. Morgan, DVM, University of British Columbia, Vancouver, Canada, dissertation in progress). Although limiting or biasing information may be an appealing prospect to avoid troubling situations, this solution reduces client autonomy and may have long-term repercussions on the veterinarian or the profession through loss of trust. For these reasons, it is important for veterinarians to discuss all morally acceptable alternatives for treatment. Some issues are subject to considerable debate within the veterinary community, and it is sometimes difcult to know whether certain alternatives are morally acceptable or not. For example, euthanasia seems to be an acceptable alternative in cases of severe illness and unacceptable in cases of mild illness. Further dialogue within the profession and between the veterinary profession and the public domain are required to clarify these areas further. Rather than withholding or limiting information, some veterinarians may use guilt or strong persuasion to manipulate clients during ethical dilemmas. The authority that veterinarians hold as part of their professional status may allow veterinarians to signicantly inuence clients. Although this authority is helpful in establishing acceptable care for patients, it is possible to abuse this authority as well [50]. Veterinarians should be cognizant of this power differential when talking with clients and staff about ethical choices and avoid

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arbitrarily substituting their own values and beliefs for those of the clients. Although it is understandable that veterinarians may believe they have a grasp of what is good for an animal or the level of care that is adequate to provide for an animal, these beliefs and determinations are not the sole territory of veterinarians. Care must be taken to engender the trust of clients. If a veterinarian believes that a client may be failing in his or her responsibilities to a patient, the veterinarians should attempt to give that client frequent and fair notice of this fact. The use of assistance from outside authorities, such as the Society for the Protection of Cruelty to Animals (SPCA), should be considered a tool to benet the situation rather than a threat or weapon. Frequently, moral decisions involving animals are emotionally charged. Hence, it is important that veterinarians and clients recognize that the stress and anxiety surrounding veterinary visits or long workdays can affect their ability to think clearly. It is important that everyone involved has enough time to reect on his or her own beliefs, the circumstances, and the potential alternatives to a problem. In emergency situations, this may be more difcult, but it is usually possible to mitigate patient pain, suffering, and anxiety while taking the time to make a reasoned and satisfactory decision. Hasty decisions in morally charged situations could have long-term consequences for patients, clients, veterinarians, and the profession. SUMMARY Veterinary medicine is rapidly evolving, and the level of care that is possible for patients is dramatically expanding. Although the perception of the importance of companion animals is changing as more people consider them family members, there is still considerable uidity and disagreement about the moral status of animals. Practitioners and clients may disagree over the importance of animals, responsibilities owed to animals, what is best for a patient, and veterinary responsibilities. Rather than making assumptions regarding clients beliefs or perceptions regarding any of these areas, veterinarians should become comfortable in discussing underlying values with clients (Appendix). Because they are not professionals, clients may not understand the range of responsibilities that veterinarians hold to various parties and the importance of maintaining the public trust. Veterinarians should remind or inform clients of these responsibilities and work on building a relationship nurtured in this understanding. Being able to understand a veterinarians dilemmas, clients may be more willing to work with the veterinarian to nd solutions that work for everyone. Nonetheless, there are situations in which the communication process is unsuccessful in resolving a moral or practical dilemma. In these situations, veterinarians should be comfortable in drawing boundaries to avoid what they consider morally inappropriate action. Tools to assist veterinarians in creating boundaries include the use of practice policies, decision-making frameworks, and deferring decisions to ethics committees. Much of this article focuses on ethical questions surrounding the treatment of veterinary patients and ways to communicate about them. These same

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principles may be used to manage communications around other ethical issues affecting veterinarians, including interactions with veterinary and nonveterinary staff, colleagues, and veterinary regulatory bodies. For example, a practitioner may discover that a colleague may not have the requisite skills to manage a surgical procedure. Rather than ignoring the problem or immediately contacting the regulatory authorities, the practitioner may wish to remind his or her colleague of his or her professional responsibility for competence and engage that individual in a plan to resolve the issue. The importance of ethical issues and recognition of morally problematic situations are likely to increase as the ability to provide a high level of care escalates. As such, self-reection on these issues by practitioners and dialogue within the profession, with clients, and within the public sphere are also likely to increase. Using the skills required for communication of medical issues is vital to elevating the dialogue of ethical issues. APPENDIX 1 Role Play Exercise 1 As a part-time associate in a busy practice in a large urban center, your next appointment is a follow-up visit on a dog seen at the local emergency facility. In reviewing the le before the appointment, you recall meeting the patient and client the previous year. You examined the patient, a 14-year-old, male, neutered Bearded Collie cross, for otitis externa and recorded in your notes that the dog was severely matted and had extremely long nails and some fecal soiling. Your recollection of the client is an eccentric older lady who seemed oblivious to the dogs poor condition and seemed to resent your recommendation to groom him. The dog was presented to the emergency clinic 2 weeks previously with hind limb paralysis. The emergency veterinarians notations indicate that there may be a vertebral fracture and possibly discospondylitis. The dog was sent home with antibiotics, prednisone, and oral analgesics to allow the client a little more time with him. Discharge instructions included a recommendation to recheck with the regular veterinarian in 3 days. The client chose not to bring the dog back for re-examination until 2 weeks after the emergency visit. The client arrives at the clinic and carries the dog into the examination room on a blanket. She tells you and your receptionist that Sparky is doing well. He is eating, bright, and able to sit up. She has stopped the pain relievers because she does not believe that he is in pain. You begin to examine the dog and discover that Sparky is in lateral recumbency, he does not seem to have pain sensation in his hind limbs, he is thin and matted, and he smells like urine. Throughout the examination, the client coos to Sparky, pets him, and reassures him. You begin talking to the client by suggesting, We need to have a conversation about quality of life. She immediately responds by saying that his life is good and that he is going to get better. After all, she didnt kill her mother when she was elderly, and Sparky is no different. She then adds that she remembers you from the visit 6 months ago because you didnt like Sparky

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because he isnt attractive. She says, aggressively, Vets shouldnt like only the cute dogs; they should like all dogs. Exercise Through role play with one person acting as the client and another as the veterinarian, how would you handle the situation?
1. Identify the source of the ethical concerns. 2. Consider diagnosing the possible sources of ethical tension in this situation through value articulation and clarication of roles. 3. How would you resolve this situation? 4. How could this situation have been avoided?

Role Play Exercise 2 In preparation for orthopedic surgery, you open the narcotic drawer in your small suburban practice and discover that there are no narcotic patches. Because you were certain that there were at least two small patches in the drawer yesterday, you ask your technician where the patches went. Mercy, your technician, has been in your employ for 6 months and seems to be doing a great job. She breaks down and says that she used the patches on two cats that were declawed the day before because they deserved pain relief. Its bad enough that we declaw them; we should control their pain at least, she says. You are surprised because you did not ask her to put patches on the cats. At your hospital, clients are asked to sign a consent form when they drop the cat off for surgery. The consent form has a box that clients can check if they would like to have postoperative analgesia at an additional cost of $35. The owner of the two cats that were declawed the previous day had declined narcotic patches. As this scenario unfolds, the owner of the two cats arrives to pick up her cats, both with patches still applied. Exercise Through role play, one person should play the veterinarian; another, the technician; and a third, the client.
What are the ethical issues in this scenario? How should the veterinarian handle the discussion with the technician and vice versa? What is the source of the ethical disagreement between the technician and the veterinarian? What should the veterinarian say to the client? How should the veterinarian respond if the client asks why postoperative anesthesia is optional? How could this situation have been avoided?

References
[1] Haidt J. The emotional dog and its rational tail: a social intuitionist approach to moral judgment. Psychol Rev 2001;108(4):81434.

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